Missing Children With Special Needs Lost-Person Questionnaire

This questionnaire should be used in conjunction with the National Center for Missing & Exploited Children®’s Missing Children With Special Needs addendum and Investigative Checklist for Law Enforcement When Responding to Missing Children With Special Needs available at the Resources for Law Enforcement section of www.missingkids.com.

For immediate assistance with the search for a missing child call the National Center for Missing & Exploited Children at 1-800-THE-LOST® (1-800-843-5678).

Incident Name Today´s Date Time Interviewed By Case Number Lost Person Full Name DOB Sex Home Address Zip + 4 Home Phone Cell Phone Physical Description Height Weight Age Build Eye Color Hair Glasses Distinguishing Marks (scars/moles/tattoos/piercings) Overall Appearance Photo Available Y N Where? Next of Kin Name Address Home Phone Cell Phone Relationship to Subject Close Friend Name Address Home Phone Cell Phone Name Address Home Phone Cell Phone Place Last Seen Time Where How Seen by Whom Weather Conditions at Time Last Seen Current Weather Conditions Direction of Travel Last Seen

Missing Children With Special Needs Questionnaire - 1 Reason for Leaving Mood (confident, confused, other) Comments Clothing/Equipment Style Color Size Other Shirt/Sweater Pants (Belt) Hat Rain Gear Gloves Shoes Sole Pattern Jacket Additional Clothing Tracking Device Family Doctor/Pediatrician Name Office Address Office Phone Cell Phone Other Contact Information Caregiver Name Address Home Phone Cell Phone School Name Address Teacher´s Name Phone Number Outdoor Experience Familiar With Area Ever Lost Before Y N When Where Health/General Condition Overall Health Overall Physical Condition Known Medical/Dental Problems Handicaps/Deformities/Prosthetics Known Psychological Problems

2 - Missing Children With Special Needs Questionnaire Medication Dosages Medication Side Effects Witness Information Name Home Address Home Phone Cell Phone Relationship Witness Comments Actions Taken By Family/Friends Results Others Results Comments

Additional Information For Children With Autism To Address Immediate Life Saving Efforts

Tracking Technology Device Worn/Carried Y N If So, How Are Tracking Measures Initiated Child Attracted to Water Y N If Specific Body of Water, Which One Child Able to Swim Y N Child Attracted to Roadways/Highways Y N If Specific, Which One(s) Child Attracted to Trains Heavy Equipment Airplanes Fire Trucks Other Vehicles, Specify Child Wandered Before Y N Where Found Child Have Siblings With Special Needs Y N Sibling Wandered Before Y N Where Found Favorite Places/Locations Child Verbal Nonverbal Reaction When Name Called Responds to Voice of Mother Father Other, Specify Favorite Song Favorite Toy Favorite Character Knows Parents´ Names Home Address Phone Number Other Contact Information, Specify Dislikes

Missing Children With Special Needs Questionnaire - 3 Fears Behavioral Triggers Reaction to Sirens Aircraft Canines/Search Dogs People in Uniform/Searchers Response to Pain/Injury Response to Being Touched Wears Medical ID Tag Y N Sensory, Medical, Dietary Issues/Requirements Methods Used to Calm Child Once Upset Special-Needs Conditions

This project was supported by Grant No. 2012-MC-FX-K001 awarded by the Office of Juvenile Justice and Delinquency Prevention, Office of Justice Programs, U.S. Department of Justice. This document is provided for informational purposes only and does not constitute legal advice or professional opinion on specific facts. Information provided in this document may not remain current or accurate, so recipients should use this document only as a starting point for their own independent research and analysis. If legal advice or other expert assistance is required, the services of a competent professional should be sought. Points of view or opinions in this document are those of the author and do not necessarily represent the official position or policies of the U.S. Department of Justice. Copyright © 2012 National Center for Missing & Exploited Children. All rights reserved. National Center for Missing & Exploited Children® and 1-800-THE-LOST® are registered trademarks of the National Center for Missing & Exploited Children.

4 - Missing Children With Special Needs Questionnaire